Accepted Manuscript A modified Delphi consensus study to identify UK osteopathic profession research priorities A.B. Rushton, EdD, MSc, MCSP, FMACP C.A. Fawkes, DO PG Cert MSc D. Carnes, BSc PhD A.P. Moore, PhD PhD FCSP FMACP Cert Ed PII:

S1356-689X(14)00078-2

DOI:

10.1016/j.math.2014.04.013

Reference:

YMATH 1560

To appear in:

Manual Therapy

Received Date: 18 December 2013 Revised Date:

24 April 2014

Accepted Date: 28 April 2014

Please cite this article as: Rushton A, Fawkes C, Carnes D, Moore A, A modified Delphi consensus study to identify UK osteopathic profession research priorities, Manual Therapy (2014), doi: 10.1016/ j.math.2014.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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A modified Delphi consensus study to identify UK osteopathic profession research priorities Rushton AB1, Fawkes CA2, Carnes D2, Moore AP3

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1. Dr Alison Rushton EdD, MSc, MCSP, FMACP

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School of Health Professions, University of Brighton, 49, Darley Road, Eastbourne, East Sussex, BN20 7UR.

Senior Lecturer in Physiotherapy, School of Sport, Exercise and Rehabilitation Sciences University of Birmingham, Edgbaston, Birmingham, B15 2TT. 2. Miss Carol Fawkes DO PG Cert MSc

2. Dr Dawn Carnes BSc PhD

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Research Officer, National Council for Osteopathic Research, Barts and The London School of Medicine and Dentistry, Centre for Primary Care and Public Health, Yvonne Carter Building, 58 Turner Street, London E1 2AB.

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Senior Research Fellow, National Council for Osteopathic Research, Barts and The London School of Medicine and Dentistry, Centre for Primary Care and Public Health, Yvonne Carter Building, 58 Turner Street, London E1 2AB.

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3. Professor Ann P Moore PhD PhD FCSP FMACP Cert Ed Professor of Physiotherapy, School of Health Professions, University of Brighton, 49, Darley Road, Eastbourne, East Sussex, BN20 7UR.

Corresponding author Email: [email protected] Telephone: 0207 882 6131

ACCEPTED MANUSCRIPT ABSTRACT

There is an increasing emphasis to take an evidence-based approach to healthcare. To obtain evidence relevant to the osteopathic profession a clear research direction is required based on A modified Delphi consensus

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the views of stakeholders in the osteopathic profession.

approach was conducted to explore the views of osteopaths and patients regarding research priorities for osteopathy.

Osteopaths and patients were invited to complete an online

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questionnaire survey (n=145). Round 1 requested up to 10 research priority areas and the rationale for their selection. All of the themes from Round 1 were fed back verbatim, and in

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Round 2 participants were asked to rank the importance of the research priorities on a 5-point Likert scale. Finally, in Round 3 participants were asked to rank the importance of a refined list of research topics which had reached consensus. Descriptive analysis and use of Kendall’s coefficient of concordance enabled interpretation of consensus. The response rate

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for Round 1 was 87.9% and identified 610 research priority areas. Round 2 identified 69 research themes as important, and Round 3 identified 20 research priority topic areas covering four themes: effectiveness of osteopathic treatment (7 areas prioritised), role of

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osteopathy: the management of four conditions were prioritised, risks with osteopathic treatment (two areas prioritised) and outcomes of osteopathic treatment (two areas

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prioritised). The findings will be taken forward to develop the research strategy for osteopathy.

ACCEPTED MANUSCRIPT A modified Delphi consensus study to identify UK osteopathic profession research priorities

INTRODUCTION Over the past decade, there has been an increasing emphasis on the need for osteopaths to take an

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evidence-based approach to their practice. This emphasis, driven by a range of stakeholders, is set to grow in both its demands and requirements. Sackett, (1998) first advocated the need for evidence-based practice underpinned by integrating the best available research with the clinicians’ However, health

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own expertise and experience to produce effective clinical decision-making.

professions are at different stages of development and maturity, and this will affect their individual

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research capacity and capability. Moore and Petty (2001) acknowledged that different health professions have varying capacity to produce the evidence on which their practice can be based, a diversity of suitable methodological approaches, and unequal levels of access to evidence by clinicians.

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One very real practical issue faced by clinicians who work outside publicly-funded healthcare, is limited access to research funding, and limited availability of financially-supported time to undertake research activity. Osteopathy is a case in point. In the UK, osteopaths work predominantly outside of

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the National Health Service (NHS), that since its launch in 1948 has grown to become the largest

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publicly funded healthcare system in the world. Research capacity and capability within the osteopathy profession is slowly growing. Implicit to the development of research within osteopathy has been its evolution into a regulated profession in the UK since the Osteopaths’ Act (1993) was passed, the subsequent creation of the National Council for Osteopathic Research (NCOR), and the growth of scholarship which is being encouraged among staff in the Osteopathic Educational Institutions.

The NCOR has supported the osteopathic profession by disseminating evidence

relevant to practice, and encouraging practice-based data collection and audit activities. Such activities, in turn, are supporting osteopaths as they engage with new opportunities introduced by

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ACCEPTED MANUSCRIPT the recent Health and Social Care Act (2012), for example the Any Qualified Provider System that enables patients to choose from a range of approved providers for their healthcare.

Historically, the focus of osteopathic research has been musculoskeletal practice in adults

et al., 2004; Williams et al., 2004; Fawkes et al., 2013).

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(MacDonald and Bell, 1990; Andersson et al., 1999; Burton et al., 2000; Williams et al., 2003; Gurry More recent research has involved

osteopaths in collaboration with physiotherapists and chiropractors delivering interventions for

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patients with low back pain (UK BEAM Trial Team, 2004a & b).

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In order to support professional development and the growth of further research in osteopathy, it is important to have a clear scope of practice. Little systematic information has been available regarding the osteopathic profession, although recent initiatives have attempted to address this. The development and piloting of a standardised data collection tool for osteopaths in 2009 has

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produced a profile of professional activity. This, in turn, has led to the development of other initiatives which will support standard setting for practice-based audit activities, and identify relevant research questions (http://www.ncor.org.uk/practitioners/patient-reported-outcomes/).

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The key to successful research development has been described as a combination of flexibility and balance in coordinating both strategic direction (top down approach) and responsive research To facilitate such development, clinician

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(bottom up approach) (Research Council UK, 2005).

engagement is important for research development in osteopathy.

Within the physiotherapy profession, work has been conducted to identify research priorities for postgraduate theses in musculoskeletal physiotherapists internationally (Rushton and Moore, 2010), and research priorities for the Chartered Society of Physiotherapy nationally (Rankin et al., 2012). Research priorities have also been identified in wound care (Serena et al., 2012), paediatric intensive care units (Ramelet and Gill, 2012), midwifery (Aguilar et al., 2013), occupational medicine 2

ACCEPTED MANUSCRIPT (Harrington, 1994), dentistry (Cramer et al., 2008), complementary therapies (Barnard et al., 1997), and nursing (Kirkwood et al., 2003). These studies all used the Delphi method to define research priorities. The Delphi method is a powerful tool to achieve consensus as it enables participation among a large group of professionals, and therefore can encompass all aspects of practice. Delphi

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has the benefit of identifying areas of practice which may be of particular concern to professionals (Rankin et al., 2012). It can also highlight areas where dissemination of research findings is most needed, and the types of methodological approach potentially required by a particular research area

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allowing approximate funding to be sought (Rushton and Moore, 2010; Rankin et al., 2012). This allows professional development to take place in a rational manner to ensure that the progress of a

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profession is strategic (Marshall, 2004).

Earlier work has also questioned the value of identifying research priorities compared to the actual research output delivered as a result of identifying such priorities (Marshall, 2004). Riegel et al

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(1993) reviewed the priorities identified by Lewandoski and Kotsisky in their 1980 research priorities study, and found that little research had been conducted in several of the identified areas. This highlights the need to maintain a focus on priorities, and identify a clear strategy for progressing

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identified research priority areas into specific research questions. It is also important to be mindful of the changing priorities for professions which are imposed from both political and social pressure.

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In view of the increasing limitations being placed on available funding, it would appear to be prudent to undertake a systematic process to identify priorities to target restricted resources.

The literature highlights the importance of the researcher and research consumer (osteopaths and patients) within the process of identifying research priorities (Rushton and Moore, 2010). The aim of this study was therefore to identify, by professional and patient consensus, key research priority areas for the osteopathic profession thereby informing the strategic research direction of the osteopathic profession in the UK. 3

ACCEPTED MANUSCRIPT METHOD

The modified Delphi consensus approach

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A modified Delphi consensus approach (Rushton and Moore, 2010; Rankin et al., 2012) was used to explore the views of osteopaths, and osteopathic patients about research priorities for the osteopathic profession in the UK. This approach has been used successfully with osteopaths in

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previous work (Carnes et al., 2010), and many of the previous research priority exercises utilised the Delphi approach. Delphi has been described as “a method for the systematic collection and

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aggregation of informed judgements from a group of experts on specific questions or issues” (Reid, 1993); and has been confirmed as providing both face (Cross, 1999) and concurrent validity (Williams and Webb, 1994) for the identified priorities.

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Osteopaths were asked to complete an online questionnaire survey through an iterative process on 3 separate occasions. The questionnaires were administered through SurveyMonkey software. Initial questions focussed on views about research priorities and priority areas (Rushton and Moore,

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2010) for the osteopathic profession. Data were summarised and fed back to respondents in two further stages to capture consensus views about priorities and to encourage prioritisation. All data

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fed back from individuals were anonymised to maintain participant confidentiality. In addition, demographic data including age, gender, location of training, years in practice, type of practice, and whether clinicians specialised in any particular area of practice, were collected. For patients, data were collected concerning their age, gender, occupation, and type of osteopathic treatment that they had received. The study was approved by the host university following ethical review.

Participant recruitment

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ACCEPTED MANUSCRIPT Osteopathic participants were invited to take part in the study by email circulation to the whole profession via the British Osteopathic Association and General Osteopathic Council email distribution lists. Advertisements were placed also on the website of these organisations and the website for the NCOR. The osteopathic participants included clinicians, researchers, and educators

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to ensure that research priorities were identified within the context of their intended use. Service users (patients) were invited to participate by information being communicated via participating osteopathic practices to potentially recruit a wide and diverse range of participants. Owing to the

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stage of development of the osteopathy profession in the UK and this being the first research

priority setting project, in contrast to previous research priority projects (Rankin et al., 2012), an

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expert panel was not established. All participants indicating an interest in taking part in the project (email or telephone), were forwarded a participant information sheet and consent form; and return of signed consent forms was requested via facsimile, post, or scanned email, depending on

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Data Collection process

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participant preference.

Round 1: All participants were asked to identify up to 10 research priority areas while also giving the

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rationale behind their choices. Participants were encouraged to discuss the task with colleagues to inform their choices. Email reminders were sent to non-responders after 3 and 6 weeks. All research priority areas suggested by participants were collated and categorised into themes / sub-themes enabling categorisation of the research priority areas. Themes were identified independently by 3 researchers (AR, CF, DC) and then collated through a process of discussion to achieve agreement.

Round 2: All participants received feedback on Round 1, consisting of a list of research priority areas grouped as themes / sub-themes, with the supporting statements provided in the original format in 5

ACCEPTED MANUSCRIPT which they were contributed. Participants were asked to rate the importance of each research priority area using a 5-point Likert scale (Disagree strongly, Disagree, No opinion, Agree, Agree strongly), and invited to make comments about the process of rating through open questions. Email

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reminders were sent to non-responders after 3 and 6 weeks.

Round 3: Participants received feedback in the form of a list of research priority areas under revised themes reaching consensus with their unadulterated supporting statements, and descriptive data

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analysis of ratings from Round 2. Participants were asked to rate each research priority area again. Participants were invited also to make comments about the process of rating. Email reminders were

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sent to non-responders again after 3 and 6 weeks.

Data analysis

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Following assumptions regarding the equality of points on the Likert Scale, it was argued as an interval scale (Kerlinger and Lee, 2000). Descriptive statistics were used to evaluate consensus agreement for research priority areas, including mean rating, median rating, and percentage

achieved:

 

Mean rating of 3.5

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agreement. Consensus was established in Round 2 if the following pre-specified criteria were

A median rating of ≥4 Percentage agreement of ≥ 60% (lower than round 3 owing to anticipated variation in responses)



Kendall’s coefficient of concordance demonstrating significant agreement across participants (p25 Private practice NHS Education Research Other Yes (includes general medical practice, acupuncture, sports medicine, and paediatrics) No Other

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Participant data Age

ACCEPTED MANUSCRIPT Table 2. Research priority themes from Round 1. Theme A. Profession of osteopathy

Subtheme Scope of osteopathy Context of practice in osteopathy Awareness of osteopathy Non-neuro-musculoskeletal problems Neuro-musculoskeletal problems Low back problems Headache Effectiveness Underlying principles Pathology in children Manipulation Provision of information Events

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B. Clinical problems

C. Cranial osteopathy

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D. Adverse events

Patient reported outcomes Physiological outcome measurement Identification and appropriate application of outcome measures Management of low back pain Management of neck pain Techniques Other

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E. Clinical diagnoses F. Outcome measurement

G. Effectiveness and cost-effectiveness

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H. Education and continuing professional development I. Visceral osteopathy J. Sports injury and rehabilitation K. Effects of osteopathic technique Musculoskeletal outcomes Physiological

ACCEPTED MANUSCRIPT Table 3 Development of underpinning principles of osteopathy research practice identified from Round 1.

Underpinning principle from Round 1

Further development in Round 2 High quality research Translational research to inform practice The most appropriate outcome measures for osteopathy need to be defined Patient satisfaction central to evaluating outcome Patient satisfaction as an essential outcome measure Pain as an essential outcome measure Evaluation of long term outcomes Development of treatment protocols Targeted treatment Osteopathic care versus other professions Osteopathic care versus standard NHS care

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Underpinning principles

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Valuable methodologies

Student dissertations

Phase III randomised controlled trials o Cost effectiveness included in trials o Appropriately powered studies o Double blinding where possible o Risk to benefit ratios for all osteopathic treatment modalities but especially HVLAT Longitudinal studies Large audits Mixed methodology research Single case study research Qualitative research to evaluate patient experience Case histories Use of the student resource to collect data Publication of student dissertations

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Research priority areas

Med ian

SD

≥ 60% agreement

3.77 3.89 3.69

4 4 4

1.24 1.29 1.33

62.22 71.43 65.31

4

1.56

61.04

4

1.54

61.64

3.69 4.01 3.83

4 4 4

1.27 1.15 1.10

64.79 70.42 69.01

3.66

4

1.26

64.79

3.80

4

1.06

64.79

3.61

4

1.30

63.38

3.87 3.74 3.76 3.76

4 4 4 4

1.09 1.27 1.23 1.20

67.61 66.67 66.67 63.64

3.73

4

1.31

61.90

3.98 3.98 3.81

4 4 4

1.22 1.26 1.34

71.43 73.02 66.67

4.00 3.89

4 4

1.31 1.31

76.19 69.84

3.71

3.63

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Theme A: Profession of osteopathy Aa1 Osteopathic scope of practice Aa6 Evidence of range of 'conditions treated' Aa16 Primary physiological research to investigate the osteopathic concept of health and the contribution of somatic dysfunction to disease Ac4 Perception of osteopathic treatment by GPs and doctors Theme B: Clinical problems Bb22 Treatment of specific disease processes, e.g. glue ear, vertigo, tinnitus, reflux, high blood pressure, infant colic, migraine etc, already known to respond well to osteopathic treatment Bc17 Neck pain-UOP Bc18 Treatment of Whiplash injuries Bc21 Osteopathic approach to treating chronic pain patients Bc22 To explore conditions that benefit most from osteopathic treatment Bc26 Effectiveness and safety of osteopathic treatment for the musculoskeletal problems associated with pregnancy Bb34 Quantitative and qualitative research into chronic pain and 'medically unexplained symptoms' Bc42 Osteopathic care for the elderly Bd1 Low back pain Bd8 Chronic low back pain and osteopathic intervention Bd10 Does Osteopathic regular maintenance treatment decreases incidence/frequency of lower back pain episodes ? Be1 Headaches / migraines - they are a common presentation and yet the aetiology is not well understood or treated Be2 Effectiveness of treating headaches and migraine Be3 Osteopathic treatment for headaches Be4 Clinical effectiveness of osteopathy in chronic headaches Theme D: Adverse effects Da1 Dangers and safety of cervical spine manipulation Da 2 Incidence of vascular accidents following osteopathic

Mean

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Research priority number

Round 2 consensus agreement topics

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Table 4.

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1.33 1.41 1.38

71.43 60.32 69.84

3.76

4

1.30

61.90

3.86 3.71 3.73 3.68 3.76 3.75

4 4 4 4 4 4

1.27 1.35 1.35 1.23 1.29 1.38

63.49 60.32 63.49 60.32 61.90 63.49

4 4

1.41 1.16

60.32 66.67

3.67

4

1.17

60.66

3.67 3.56

4 4

1.17 1.25

63.93 62.30

3.64

4

1.24

65.57

3.88

4

1.13

67.24

3.62

4

1.27

62.07

3.69

4

1.29

65.52

3.59

4

1.30

62.07

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3.95 3.68 3.84

3.67 3.94

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manipulation Da 3 HVT safety and risks in practice Da 4 VAI and manipulations Da 5 What exactly is the risk of serious damage caused by cervical manipulation? Da 6 Risk to benefit ratios for all osteopathic treatment modalities but especially HVLAT Db1 Safety of Osteopathic treatment Db2 Assess risks of osteopathic treatment Db3 Contraindications of cervical spine thrust techniques Dc2 The risks associated with osteopathic treatment Dc3 Identify prevalence of adverse events Dc4 Comparison of risk of osteopathic treatment with pharmaceutical intervention Dc6 How safe is Osteopathy Dc8 Development of an reporting system for serious adverse reactions Theme F: Outcome measures Fa1 Patient Reported Outcome Measure standardising this for osteopathy - validating a tool Fa3 Patient satisfaction with treatment outcome Fa4 Is there a significant reduction in pain after a course of osteopathic treatment? Fa5 Patient recorded outcome statistics Theme G: Effectiveness and cost-effectiveness Gb3 Effectiveness of osteopathy in the treatment of whiplash injuries Gc1 Is osteopathy effective for non-specific pain in shoulder / knee/ hip? Gc5 Tension headaches - the efficacy of osteopathic treatment Theme K: Effects of osteopathy techniques Ka2 Understanding of the underlying science behind osteopathy's effectiveness

Table 5. Research priorities with ≥ 70% agreement in round 3.

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CV

4.41

Media n 5

0.84

19.05

% agree 93.10

Effectiveness of osteopathy Effectiveness of osteopathy

4.26

4.5

0.98

23.00

86.21

Effectiveness of osteopathy

4.29

4.5

0.88

20.51

84.48

Effectiveness of osteopathy

4.21

4

Effectiveness of osteopathy

4.17

4

Effectiveness of osteopathy

4.09

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Mean

0.95

22.57

82.76

0.96

23.02

81.03

0.98

23.96

81.03

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Theme

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4

Adverse effects

4.12

4

1.05

25.49

77.19

Effectiveness of osteopathy

4.09

4

0.92

22.49

75.86

Practice of osteopathy

3.97

4

1.04

26.20

75.86

Practice of osteopathy Practice of osteopathy

3.97

4

1.00

25.19

72.13

4.00

4

1.21

30.25

72.13

Effectiveness of osteopathy Effectiveness of osteopathy

4.02

4

0.95

23.63

72.41

3.93

4

0.86

21.88

72.41

Effectiveness of osteopathy

3.95

4

0.96

24.30

72.41

Effectiveness of osteopathy Effectiveness of osteopathy Effectiveness of

4.03

4

1.12

27.79

70.69

4.12

4.5

1.09

26.46

74.14

3.97

4

1.09

27.46

74.14

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Research priority (rated as ≥ 70% agreement most important, then mean) 1. What is the effectiveness of osteopathy for neck pain? 2. What is the effectiveness of osteopathy for chronic low back pain? 3. What is the effectiveness of osteopathy for whiplash injuries? 4. What is the effectiveness of osteopathy for radicular symptoms? 5. What is the effectiveness of osteopathy for cervicogenic headache (headache of cervical origin)? 6. What is the effectiveness of osteopathy for tension-type headache (primary and / or secondary headache related to muscle tension, stress, psychogenic causes)? 7. What are the risks of osteopathic intervention compared to pharmaceutical intervention? 8. What is the effectiveness of osteopathy management of age related complaints in the elderly? 9. What approaches do osteopaths take in managing patients with widespread chronic pain? 10. What are the neurological effects of osteopathy interventions? 11. Development of an osteopathic specific patient reported outcome measure and evaluation of its measurement properties. 12. What is the effectiveness of osteopathy for migraine? 13. What is the effectiveness and safety of osteopathy management of musculoskeletal problems in patients who are pregnant? 14. What is the effectiveness of osteopathy for spinal pain arising from injury / accident? 15. What is the effectiveness of osteopathy for acute low back pain? 16. What is the effectiveness of osteopathy for sciatica? 17. What is the effectiveness of ongoing

Table 5. Research priorities with ≥ 70% agreement in round 3.

ACCEPTED MANUSCRIPT osteopathy 3.91

4

1.08

27.62

72.41

Adverse effects

4.04

4

1.21

29.95

73.68

Adverse effects

4.05

4

1.11

27.41

72.41

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Effectiveness of osteopathy

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regular osteopathy treatment in reducing incidence / frequency of episodes of LBP? 18. What is the effectiveness of nonmanipulative osteopathy management of low back pain? 19. What are the risks of osteopathic cervical manipulation? 20. What is the rate and nature of reported adverse events?

ACCEPTED MANUSCRIPT Table 6 Summary of priority areas

Risk of osteopathic treatment:

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Outcomes of osteopathic treatment:

• • • •

Neck pain Whiplash Headaches Radicular pain (including sciatica) Reducing episodes of low back pain (LBP) Acute LBP Chronic LBP Chronic widespread pain Musculoskeletal pain in pregnancy Elderly Spinal pain resulting from accident and or injury Compared to pharmacological therapy In cervical spine manipulation Patient reported outcomes Effect on the neurological system

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Role of osteopathy in the management of:

• • • • • • • • • • •

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Effectiveness of osteopathic treatment for:

A modified Delphi consensus study to identify UK osteopathic profession research priorities.

There is an increasing emphasis to take an evidence-based approach to healthcare. To obtain evidence relevant to the osteopathic profession a clear re...
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